What is the treatment plan for a complete lateral collateral ligament injury with anterior capsular injury and a displaced coronoid process?

Treatment of Complete Lateral Collateral Ligament Injury with Anterior Capsular Injury and Displaced Coronoid Process

This complex elbow injury pattern requires urgent surgical intervention using a standardized protocol: radial head fixation/replacement, coronoid fixation (if fragment is large enough), lateral collateral ligament repair, and anterior capsular repair, followed by early motion within 7-10 days postoperatively to optimize functional outcomes and prevent stiffness. 1

Injury Pattern Recognition

This represents a variant of the "terrible triad" of the elbow, which combines:

• Elbow dislocation (implied by the ligamentous and capsular injuries)
• Lateral collateral ligament (LCL) disruption
• Anterior capsular injury
• Displaced coronoid process fracture

This injury pattern creates combined sagittal, frontal, and transverse instability, making it notoriously difficult to treat and requiring comprehensive surgical stabilization. 2

Surgical Treatment Algorithm

Primary Surgical Approach

Use a lateral approach to the elbow as the primary surgical corridor, which provides access to the radial head, LCL, and anterior capsule. 1, 2

• A curvilinear incision centered over the lateral epicondyle allows exposure of all lateral structures 3
• This single lateral approach enables "deep to superficial" stabilization, addressing all components of instability 2
• An anterior approach may be added if the coronoid fragment requires direct visualization for anatomic reduction 4

Surgical Sequence: Deep to Superficial Stabilization

The key principle is to restore stability from the deepest structures outward, in this specific order:

1. Coronoid Process Management

The decision to fix the coronoid depends on fragment size:

• For Regan-Morrey Type I (tip fractures) or small Type II fragments: Coronoid fixation may be omitted if the elbow achieves stability after radial head treatment and ligament repair 5
• For larger displaced fragments (Type II-III): Fix the coronoid using suture lasso technique, suture anchors, or lag screws with buttress plating 1, 4
• Priority hierarchy: If the elbow remains unstable after radial head and LCL repair, repair the medial collateral ligament (MCL) rather than pursuing small coronoid fixation 5

2. Anterior Capsular Repair

Repair the anterior capsule using absorbable suture anchors to restore anterior stability. 2

• This addresses the sagittal plane instability component
• Reinsertion should be performed before addressing the lateral ligaments 2

3. Lateral Collateral Ligament Repair

Repair the LCL complex anatomically, with consideration for internal brace augmentation to allow early mobilization. 3

• Place #5 FiberWire sutures into the distal LCL and any avulsed structures 3
• Create a tunnel in the fibular head and secure with suspensory fixation 3
• Internal brace augmentation (using FiberTape or similar) provides additional stability and facilitates early range of motion 3
• Tension the repair in near-full extension, matching gapping to the contralateral elbow fluoroscopically 3

4. Assessment for Additional Stabilization

After completing the above repairs, assess elbow stability through a full range of motion under fluoroscopy:

• If concentric reduction is maintained through flexion-extension and forearm rotation, no additional procedures are needed 1
• If persistent instability exists, consider MCL repair (if torn) or hinged external fixation 1
• External fixation should be reserved for cases where stability cannot be achieved through ligament repair alone 1

Postoperative Rehabilitation Protocol

Begin early active motion at 7-10 days postoperatively to prevent stiffness while the stable fixation protects healing structures. 1

• Early functional rehabilitation is critical to achieving good outcomes 1
• The goal of stable surgical fixation is specifically to enable this early motion 1
• Prolonged immobilization leads to poor outcomes with stiffness and recurrent instability 1

Expected Outcomes

With this standardized surgical protocol, you can expect:

• Mean flexion-extension arc of 112° at 34 months follow-up 1
• Mean forearm rotation of 136° 1
• Mean Mayo Elbow Performance Score of 88 points (78% excellent or good results) 1
• Concentric stability restored in 94% of cases 1
• Complication rate requiring reoperation approximately 22% (hardware removal, synostosis, or stiffness requiring release) 1

Critical Pitfalls to Avoid

Failure to address all components of instability leads to recurrent subluxation and progression to painful arthrosis. 4

• Do not treat these injuries non-operatively or with isolated component repair 2
• Do not delay surgery—early operative intervention within days of injury optimizes outcomes 1
• Do not immobilize for extended periods—this defeats the purpose of stable fixation and leads to stiffness 1
• Do not fixate on repairing small coronoid fragments if the elbow is stable without it—focus on MCL repair instead if instability persists 5